Dr. Ajaya N Jha
nstitute of Neurosciences
Emergency treatment for stroke depends on whether you're having an ischemic stroke blocking an artery, the most common kind or a haemorrhagic stroke involving bleeding into the brain.
To treat an ischemic stroke, doctors must quickly restore blood flow to your brain.
Emergency treatment with medications
Therapy with clot-busting drugs (thrombolytics) must start within 4.5 hours if they are given into the vein - and the sooner, the better. Quick treatment not only improves your chances of survival but also may reduce the complications from your stroke. You may be given:
Aspirin, an anti-thrombotic drug, is an immediate treatment after an ischemic stroke to reduce the likelihood of having another stroke. Aspirin prevents blood clots from forming. In the emergency room, you may be given a dose of aspirin. The dose may vary, but if you already take a daily aspirin for its blood-thinning effect, you may want to make a note of that on an emergency medical card so doctors will know if you've already taken some aspirin.
Other blood-thinning drugs, such as heparin, also may be given, but this drug isn't proven to be beneficial in the emergency setting so it's used infrequently. Clopidogrel (Plavix), warfarin (Coumadin) or aspirin in combination with extended release dipyridamole (Aggrenox) may also be used, but these aren't usually used in the emergency room setting.
The rtPA is the only drug approved by US FDA and recommended by the National Stroke Societies worldwide including American and European Stroke Association for the treatment of acute ischemic stroke within 4.5 hours from the onset of stroke. This drug is known as 'clot buster' in layman's language and it helps dissolving the clot in the blocked vessel. It is given via intravenous (IV) infusion. Ideally it should be given at a centre well equipped with facilities to do CT scan and a team of doctors comprising of Stroke Neurologist, Interventional Neuroradiologist, Neurointensivist, Neurosurgeon and Stroke Nurse Practitioner collectively referred to as a "Stroke team".
Following are the internationally accepted criteria for eligibility to receive IV rtPA:
The rtPA is administered intravenously in the dose of 0.9 mg/Kg body weight with a maximum of 90 mg. 10% of the dose is administered as a bolus and remaining 90% is given as a continuous infusion over 01 hour. Following rtPA, patient is monitored for neurological parameters in the Neuro-ICU. Patient is not given any other blood thinner for the next 24 hours. A repeat CT scan of the brain is performed after 24 hours and if there is no haemorrhage, Aspirin is started.
It must be remembered that rtPA does not always result in rapid recovery from stroke symptoms. It does dissolve the clot and improves the chances of recovery by 35 – 40% at 03 months from the time of stroke. However there are select group of patients who do show dramatic recovery in a shorter time frame (within hours) with rtPA.
The location of the clot in the vascular tree is the prime factor which decides the extent of recovery of stroke symptoms with rtPA. Clots those are located in the vessel in the neck (ICA – Internal Carotid Artery) and large vessel in the brain do not lysis satisfactorily with rtPA, while clots located in the more peripheral and smaller vessels in the brain lysis more often. Large vessel blockages might need additional measures for opening up of the vessel with the means of mechanical Thrombectomy performed by the Interventional Neuroradiologists who form an integral part of an acute stroke treating centre.
This drug does carry a risk of intracranial haemorrhage. Based on the evidence from various trials and current guidelines, the risk of bleeding into the brain ranges from 3 – 6 %. This can sometimes be fatal and life threatening. The risk of bleeding is higher in elderly patients with pre-existing extensive brain damage. It also poses a risk of bleeding into other organs especially the stomach/intestine and urinary tract.
Decision to give IV rtPA is based on assessment of risk/benefit ratio and after detailed discussion with the family. Currently in India, majority of the tertiary care centres managing acute strokes have a protocol of getting informed consent from the patient's family member before administering rtPA.
Interventional neuroradiological procedures are a less-invasive means of treating neurovascular disorders. They use very small catheters, called microcatheters, to treat problems inside blood vessels. The microcatheter is inserted into the vessels/ arteries through a tiny puncture in the groin, where an interventional neuroradiologist can reach almost any vessel/ artery in the brain or spinal cord. These endovascular approaches can be used to open narrowed or blocked arteries, dissolve clots in brain arteries, repair certain aneurysms and close abnormal blood vessels that are at risk of bleeding. These methods often avoid the need for more invasive surgery.
A stroke is a medical emergency. Emergent treatment is needed. People who are having stroke symptoms need to get to a hospital as quickly as possible.
Usually these treatments can be done upto 8 hours form the onset of symptoms but in individual cases it may vary depending on the results of the specialized CT/MR scans.
These involve the use of a technique in which clot-dissolving drugs are delivered directly into the blood clot by placing a catheter into the blocked artery in the brain. This technique is very similar to a cardiac catheterization procedure for heart attack to open blocked heart arteries. This technique is more successful than IV tPA at dissolving blood clots in the large brain arteries and can be used in some patients who don't qualify for IV tPA treatment.
There are special stents (mesh of wires) designed to engage the clot .The clot gets trapped into the stent and the stent is then pulled out effectively opening up the vessel. The advantage is that the process of taking out the clot is faster, more effective and safer. In particular, the risk of brain bleeding is low.
Example of a stent retriever is shown.
(An artist's rendition of a stent retriever extending into the brain vessel.)
The procedures are successful in approx 80% of the patients. In some patients with very hard clot it may be difficult to dissolve the clot or pull out the clot. The additional risk of brain bleeding due to procedure is less than 5%. Even if the artery opens up completely it may take weeks before the patient can improve and be discharged home. If you are a candidate for these alternative treatments, the doctor will review the risks and benefits and may have you review and sign special consent forms or study forms that explain these in detail.
Sometimes the cause for stroke may be due to narrowing of a major blood vessel of the brain (Carotid artery). This procedure helps widen a narrowed/blocked artery. A catheter with a balloon at the end is inserted into the narrowed artery and the balloon is inflated, pushing the plaque against the walls. A stent or a mesh steel brace, is then inserted to keep fatty buildup from clogging the vessel. These procedures can be done immediately or on non urgent basis depending on the clinical condition.
To decrease your risk of having another stroke or TIA, your doctor may recommend a procedure to open up an artery that is moderately to severely narrowed by plaque. Doctors sometimes recommend these procedures to prevent a stroke. Options may include:
In a carotid endarterectomy, a surgeon removes fatty deposits (plaques) from your carotid arteries that run along each side of your neck to your brain. In this procedure, your surgeon makes an incision along the front of your neck, opens your carotid artery and removes fatty deposits (plaques) that block the carotid artery. Your surgeon then repairs the artery with stitches or a patch made with a vein or artificial material (graft). The procedure may reduce your risk of ischemic stroke. However, a carotid endarterectomy also involves risks, especially for people with heart disease or other medical conditions.
In an angioplasty, a surgeon inserts a catheter with a mesh tube (stent) and balloon on the tip into an artery in your groin and guides it to the blocked carotid artery in your neck. Your surgeon inflates the balloon in the narrowed artery and inserts a mesh tube (stent) into the opening to keep your artery from becoming narrowed after the procedure.
Emergency treatment of haemorrhagic stroke focuses on controlling your bleeding and reducing pressure in your brain. Surgery also may be used to help reduce future risk.
If you take warfarin (Coumadin) or anti-platelet drugs such as clopidogrel (Plavix) to prevent blood clots, you may be given drugs or transfusions of blood products to counteract their effects. You may also be given drugs to lower pressure in your brain (intracranial pressure), lower your blood pressure or prevent seizures. People having a haemorrhagic stroke can't be given clot-busters such as aspirin and TPA, because these drugs may worsen bleeding.
Once the bleeding in your brain stops, treatment usually involves bed rest and supportive medical care while your body absorbs the blood. Healing is similar to what happens while a bad bruise goes away. If the area of bleeding is large, surgery may be used in certain cases to remove the blood and relieve pressure on the brain.
Surgery may be used to repair certain blood vessel abnormalities associated with haemorrhagic strokes. Your doctor may recommend one of these procedures after a stroke or if you're at high risk of a spontaneous aneurysm or arteriovenous malformation (AVM) rupture.
Your doctor will consider several factors before deciding the best treatment for you. Things that will determine the type of treatment you receive include your age, size of the aneurysm, any additional risk factors and your overall health.
Because the risk of a small (less than 10 mm) aneurysm rupturing is low and surgery for a brain aneurysm is often risky, your doctor may want to continue to observe your condition rather than perform surgery. If your aneurysm is large or causing pain or other symptoms, though or if you have had a previous ruptured aneurysm, your doctor may recommend surgery.
The following surgeries are used to treat both ruptured and un-ruptured brain aneurysms:
During this procedure, a small tube is inserted into the affected artery and positioned near the aneurysm. Tiny metal coils are then moved through the tube into the aneurysm, relieving pressure on the aneurysm and making it less likely to rupture. This procedure is less invasive and is believed to be safer than surgical clipping, although it may not be as effective at reducing the risk of a later rupture. It should be done in a large hospital where many such procedures are done.
This surgery involves placing a small metal clip around the base of the aneurysm to isolate it from normal blood circulation. This decreases the pressure on the aneurysm and prevents it from rupturing. Whether this surgery can be done depends on the location of the aneurysm, its size and your general health.
Some aneurysms bulge in such a way that the aneurysm has to be cut out and the ends of the blood vessel stitched together, but this is very rare. Sometimes the artery is not long enough to stitch together and a piece of another artery has to be used.
Aneurysms that have bled are very serious and in many cases lead to death or disability. Management includes hospitalization, intensive care to relieve pressure in the brain and maintain breathing and vital functions (such as blood pressure) and treatment to prevent re bleeding.
Medanta - The Medicity is the only hospital in the region to be both a state-designated comprehensive stroke centre with its own 'Rescue Acute Stroke Team', team of stroke experts. As the treatment may involve multi-disciplinary teams of specialists, who are adept at working together in a variety of settings from the endovascular lab, to the operating room, to the catheterization lab to interventional radiology. Our team's neuro specialists work closely together on a range of procedures across specialties and disciplines in the new state-of-the-art hybrid operating room. This includes 3-D bi-plane imaging which allows clear viewing for the surgeons to place devices or perform surgery with greater precision and accuracy.
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